Treating hyperglycemia on a BLS level.

[akflightmedic]

In Alaska Vent.

 

[daedalus]

Not in most of CA or FL. An RN (MICN -CA) will usually accompany the patient. There are other drips that they can monitor but not titrate. Neither state has an official state title of CCEMT-P. The scope in CA, is of course, on a county by county basis. Florida's scope can be medical director dependent for specialty.

I think I may live in the one county in SoCal that allows paramedic transport of nitro and heparin drips, for "heart express" calls. (Emergency STEMI transport to a hospital capable of PCI)

Vent, an MICN in california is an RN who is trained by the county to give "orders" to paramedics over the radio. They must follow the exact protocol the paramedics are required to learn so the whole thing is an extreme exercise in redundancy. For example, the Chest pain protocol may allow IV placement, O2 administration, Cardiac monitoring and up to 2 sprays of nitro before contact to the base hospital. The protocol than goes on to order the use of aspirin and morphine after asking the nurse. The paramedic knows exactly what the nurse can order per the protocol.

An RN on a CCT truck need not be an MICN. In fact, none of the CCT RNs at my service are MICNs, the only requirement is 2 years of critical care or ER experience, ACLS and PALS, and an RN license. Some companies mandate CEN or CCRN.

There are CCT RNs who are also MICNs but this is the exception, as MICNs are very very well paid in the ERs around here and have a very low patient load.

 

[Jon]

You tossing 220 out as an example reflects the lack of knowledge you posses in regards to care and treatment needed for diabetic patients.

Do them a favor and transport.

Do yourself a favor and continue advancing your medical education and once you are at an educated and experienced level to treat these sort of things, you will look back and realize how silly you once were.

Yes, I was silly. I still am silly. I learn more each year, look back and say, man...just last year I was silly.

I really, really do not need you tell me that I don't know how to care and treat diabetic patients and that my question "reflects the lack of knowledge" that I posses.

I am not yet an EMT and I have not yet taken an EMT class. I'm an explorer who is trying to learn a few things about patient care.

If you didn't mean that as an insult, I apologize for jumping out on you like that....

Anyways,

Let's say the pt is not diabetic, and has a BGL of 220 and is "not feeling right"... What can cause that? And once again, there is nothing that can be done for the pt? Is there anything that can cause a false-high reading?

Explorer:

I don't think AK was trying to jump down your throat... he was just making a point that prehospitally, hyperglycemia doesn't become an issue unless it is REALLY, REALLY elevated... like 400/500 or more...

Now.. for some more questions:
What state are you in? Do you have glucometers at the BLS level?
How do you know the BGL is that high?
When was the meter last calibrated?


Jon

 

[Sasha]

When was the meter last calibrated?

Very good point!! At my old job one day we had a glucometer that was so out of callibration it was throwing us for a loop. We were getting readings in the low 40s for a patient just sitting there fine and dandy, decided to hold off on oral glucose due to the fact she wasn't presenting like a BGL of 40 something normally would, re-check at the hospital showed they were actually at a normal range :]

 

[rescuepoppy]

Very good point!! At my old job one day we had a glucometer that was so out of callibration it was throwing us for a loop. We were getting readings in the low 40s for a patient just sitting there fine and dandy, decided to hold off on oral glucose due to the fact she wasn't presenting like a BGL of 40 something normally would, re-check at the hospital showed they were actually at a normal range :]

A great point about treating the patient not the numbers. We all know that all of our toys are man made machines that can and will at some time fail. Hence the need to use your skills of evaluation.

 

[Arkymedic]

Not allowing the alcohol from the prep pad to dry can cause a false reading. Have seen several report a high CBG and then we took it to get a normal reading. When I do a CBG, I always wipe the first drop of blood I squeeze out off and use the second to ensure a better read.

I really, really do not need you tell me that I don't know how to care and treat diabetic patients and that my question "reflects the lack of knowledge" that I posses.

I am not yet an EMT and I have not yet taken an EMT class. I'm an explorer who is trying to learn a few things about patient care.

If you didn't mean that as an insult, I apologize for jumping out on you like that....

Anyways,

Let's say the pt is not diabetic, and has a BGL of 220 and is "not feeling right"... What can cause that? And once again, there is nothing that can be done for the pt? Is there anything that can cause a false-high reading?

 

[Arkymedic]

Please lead us down that road Vent. I love learning from you and Rid and the discussion that occurs. I also think since diabetic emergencies are a large portion of call volume, it will benefit all.

This is what I was referring to by DKA vs HHS (Hyperglycemic Hyperosmolar state) in an earlier post.

Once glucose gets over 600 mg/dl it may not display the same symptoms as ketoacidosis. There is a differential diagnosis to be made here.

 

[marineman]

When was the meter last calibrated?
Jon

Ok, I'll bite. How often does everyone calibrate theirs? we have the simple test strips you put in and if the glucometer comes up with the same number you're good to go. That's part of our daily rig check and of all the things people jump over that's one thing that seems to actually get checked daily.

 

[Ridryder911]

If you have noticed I have not been posting as much in the past two weeks. The reason being, I was recently diagnosed as a Diabetic and having HTN. Unfortunately, I have to admit that I realized what was occurring with the classical .."3 P's"... Polydispia, polyuria & polyphagia & passing some ketones. As a typical medic & nurse, I continued to work. Even knowing most physicians in town I was not able to be seen in their clinic for a while.

I will admit having high sugar is a horrible feeling. I have been blessed to never had been ill or ever had to take medications...something that changed. Discussing my s/s with my EMS director he bluntly questioned me on "really how do you know that is what it is?"... As one being chicken to even do a FSBS, my crew members basically infringed me and performed one. It would only read high. That was enough persuasion for my director to notify a P.A. friend of our service and was able to see him immediately. My fasting glucose was 670mg/d and for the first time ever had HTN. The P.A. of course decided to relieve me of some additional poundage from my gluteal area..giving a well deserved arse chewing; describing I should know better.

Well its been two weeks. My body is still adjusting to taking med.'s and fortunately the glucose and BP has maintained within reason. I will say lower your sugar 500 points even over time is not fun, but better than the alternative.

So it was an awakening and life changing event. I am proud to say I have continued to eat properly (within reason) and have a exercise program. I also have formally moved into my position of only being on the truck as needed. Yeah, its hard to pass the touch but I have a few that will do good. Now, all shifts will have to deal with me.

The reason I am posting, I might suggest for ALS to administer fluid therapy (if the patient can tolerate such) for dilution. I would NEVER recommend Insulin for several reasons. There are very few true hyperglycemic emergencies that EMS can treat accurately. Even DKA patients usually require glucose levels to be performed twice or diluted as most FSBS do not > 500 or definitely NOT reliable to make an accurate adjustment. As well there is a major difference between Diabetes Mellitus and Diabetes Insipidus, Non-ketonic Hyperosmolar syndrome. Without proper lab data, you are risking a lot. Regular Insulin should be adjusted accordingly and can be very DANGEROUS even administered by a well educated Paramedic. Even short acting Insulin can have rebound effects when combined with regular Insulin IV. I would presume that prehospital orders for Insulin would be based upon known diabetics and are more a sliding scale, than initial treatment.

I can understand patients in DKA; and with the use of EtCo2 in aiding my dx of DKA. I might call for orders for fluids and a NaHCo3 drip.

In regards to Insulin drip, the CCEMT-P program addresses such administration of Insulin and maintenance drip. Alike Heparin, it should be double checked and monitored closely with assigned periodical FSBS and only per IV pump with special tubing.

R/r 911

 

[marineman]

Man rid, I was just going to comment the other day asking where you had been lately. Glad you got it taken care of and it apparently didn't kill off any of those brain cells, another good post.

 

[MSDeltaFlt]

If you have noticed I have not been posting as much in the past two weeks. The reason being, I was recently diagnosed as a Diabetic and having HTN. Unfortunately, I have to admit that I realized what was occurring with the classical .."3 P's"... Polydispia, polyuria & polyphagia & passing some ketones. As a typical medic & nurse, I continued to work. Even knowing most physicians in town I was not able to be seen in their clinic for a while.

I will admit having high sugar is a horrible feeling. I have been blessed to never had been ill or ever had to take medications...something that changed. Discussing my s/s with my EMS director he bluntly questioned me on "really how do you know that is what it is?"... As one being chicken to even do a FSBS, my crew members basically infringed me and performed one. It would only read high. That was enough persuasion for my director to notify a P.A. friend of our service and was able to see him immediately. My fasting glucose was 670mg/d and for the first time ever had HTN. The P.A. of course decided to relieve me of some additional poundage from my gluteal area..giving a well deserved arse chewing; describing I should know better.

Well its been two weeks. My body is still adjusting to taking med.'s and fortunately the glucose and BP has maintained within reason. I will say lower your sugar 500 points even over time is not fun, but better than the alternative.

So it was an awakening and life changing event. I am proud to say I have continued to eat properly (within reason) and have a exercise program. I also have formally moved into my position of only being on the truck as needed. Yeah, its hard to pass the touch but I have a few that will do good. Now, all shifts will have to deal with me.

The reason I am posting, I might suggest for ALS to administer fluid therapy (if the patient can tolerate such) for dilution. I would NEVER recommend Insulin for several reasons. There are very few true hyperglycemic emergencies that EMS can treat accurately. Even DKA patients usually require glucose levels to be performed twice or diluted as most FSBS do not > 500 or definitely NOT reliable to make an accurate adjustment. As well there is a major difference between Diabetes Mellitus and Diabetes Insipidus, Non-ketonic Hyperosmolar syndrome. Without proper lab data, you are risking a lot. Regular Insulin should be adjusted accordingly and can be very DANGEROUS even administered by a well educated Paramedic. Even short acting Insulin can have rebound effects when combined with regular Insulin IV. I would presume that prehospital orders for Insulin would be based upon known diabetics and are more a sliding scale, than initial treatment.

I can understand patients in DKA; and with the use of EtCo2 in aiding my dx of DKA. I might call for orders for fluids and a NaHCo3 drip.

In regards to Insulin drip, the CCEMT-P program addresses such administration of Insulin and maintenance drip. Alike Heparin, it should be double checked and monitored closely with assigned periodical FSBS and only per IV pump with special tubing.

R/r 911

Careful, though. Hyperglycemic pts tend to die, not from from hyperglycemia, but from cerebral edema from too much fluid. Blood glucose levels need to trend down; not drop like a stone.

Glad you're back, Rid. Vent always thought you were sweet. Now there's clinical proof.

Sorry, guys. The shot was there. I had to take it.

 

[ErinCooley]

Ok, I'll bite. How often does everyone calibrate theirs? we have the simple test strips you put in and if the glucometer comes up with the same number you're good to go. That's part of our daily rig check and of all the things people jump over that's one thing that seems to actually get checked daily.

Ditto... I do the same thing @ the beginning of each shift along with the rest of my check off duties.

I'm confused....Is a typical BLS crew not allowed to begin IV fluids in some states? In Ga, if I'm an the truck w/ another EMT-I, working as a bls crew, i can still begin fluid therapy.

 

[JPINFV]

I would venture to say that it's typical of crews comprised only of EMT-Bs in most states to be unable to initiate an IV.

 

[Arkymedic]

Glad to have you back here Rid. I missed your thoughtful insights and food for thought. Hopefully you will keep taking care of yourself and you can manage this thing.

If you have noticed I have not been posting as much in the past two weeks. The reason being, I was recently diagnosed as a Diabetic and having HTN. Unfortunately, I have to admit that I realized what was occurring with the classical .."3 P's"... Polydispia, polyuria & polyphagia & passing some ketones. As a typical medic & nurse, I continued to work. Even knowing most physicians in town I was not able to be seen in their clinic for a while.

I will admit having high sugar is a horrible feeling. I have been blessed to never had been ill or ever had to take medications...something that changed. Discussing my s/s with my EMS director he bluntly questioned me on "really how do you know that is what it is?"... As one being chicken to even do a FSBS, my crew members basically infringed me and performed one. It would only read high. That was enough persuasion for my director to notify a P.A. friend of our service and was able to see him immediately. My fasting glucose was 670mg/d and for the first time ever had HTN. The P.A. of course decided to relieve me of some additional poundage from my gluteal area..giving a well deserved arse chewing; describing I should know better.

Well its been two weeks. My body is still adjusting to taking med.'s and fortunately the glucose and BP has maintained within reason. I will say lower your sugar 500 points even over time is not fun, but better than the alternative.

So it was an awakening and life changing event. I am proud to say I have continued to eat properly (within reason) and have a exercise program. I also have formally moved into my position of only being on the truck as needed. Yeah, its hard to pass the touch but I have a few that will do good. Now, all shifts will have to deal with me.

The reason I am posting, I might suggest for ALS to administer fluid therapy (if the patient can tolerate such) for dilution. I would NEVER recommend Insulin for several reasons. There are very few true hyperglycemic emergencies that EMS can treat accurately. Even DKA patients usually require glucose levels to be performed twice or diluted as most FSBS do not > 500 or definitely NOT reliable to make an accurate adjustment. As well there is a major difference between Diabetes Mellitus and Diabetes Insipidus, Non-ketonic Hyperosmolar syndrome. Without proper lab data, you are risking a lot. Regular Insulin should be adjusted accordingly and can be very DANGEROUS even administered by a well educated Paramedic. Even short acting Insulin can have rebound effects when combined with regular Insulin IV. I would presume that prehospital orders for Insulin would be based upon known diabetics and are more a sliding scale, than initial treatment.

I can understand patients in DKA; and with the use of EtCo2 in aiding my dx of DKA. I might call for orders for fluids and a NaHCo3 drip.

In regards to Insulin drip, the CCEMT-P program addresses such administration of Insulin and maintenance drip. Alike Heparin, it should be double checked and monitored closely with assigned periodical FSBS and only per IV pump with special tubing.

R/r 911

 

[Sasha]

Ok, I'll bite. How often does everyone calibrate theirs? we have the simple test strips you put in and if the glucometer comes up with the same number you're good to go. That's part of our daily rig check and of all the things people jump over that's one thing that seems to actually get checked daily.

THAT'S what that's for?

Just kidding! I tend to use the little tester strip thing when I do the truck check in the morning, that morning I was on a different truck and somehow the test strip slipped my mind.

 

[EeyoreEMT]

You would be surprised how many EMTs B-P, don't check their equipment or even clean them. It is totally so gross, plus, like duh, it could give you a false reading.

 

[exodus]

Ditto... I do the same thing @ the beginning of each shift along with the rest of my check off duties.

I'm confused....Is a typical BLS crew not allowed to begin IV fluids in some states? In Ga, if I'm an the truck w/ another EMT-I, working as a bls crew, i can still begin fluid therapy.

EMT-B Can't puncture skin other than EPI, but EMT-I can do IV's I think. Don't quote me on that.

And Explorer, how would you even know what the BGL is since you can't test it as a basic? Only way is to have a family member or the PT test it. But if we get reliable information, in San Diego County, if the pT has a history of Diabetes, we administer oral glucose as long as the pt is able to swallow per protocol. Edit: Without a BGL reading. Just altered.

 

[Summit]

False readings can occur if the meter is not properly coded, unwashed hands, ALTITUDE, anxiety, water or alcohol still on the finger at the time of sampling.

That's a new one... altitude gives false readings why?

 

[VentMedic]

That's a new one... altitude gives false readings why?

Many medical devices are calibrated by barometric pressure.

For my equipment including any blood testing devices, I calibrate by two barometric pressure measuring devices in the Pulmonary lab as well as a check with the local authorized weather reporting agency to ensure accuracy.

 

[Sasha]

And Explorer, how would you even know what the BGL is since you can't test it as a basic?

Maybe your area can't, but some areas do allow BGL testing at the basic level.

Before I started bopping around on this site, I had no idea that there were areas that didn't allow basics to do BGL finger sticks. Suprising, since you gotta be pretty dumb to mess up one of those.